Skip to content

11/13/24, 8\:08 PM Guide | Back pain history

Back pain history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Open vs closed questions
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 1/811/13/24, 8\:08 PM Guide | Back pain history
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

The SOCRATES acronym (explained below) is a useful tool that can be used to explore a patient's back pain.
Site
Ask about the location of the back pain\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Common back pain locations
Pathology typically associated with di
Pain directly overlying the spine\: spinal fracture or arthritis.
Paraspinal\: muscle spasm or muscle sprain.
Lateral back pain\: renal pain (e.g. pyelonephritis, renal colic), pleuritic pain (e.g. pulmonary embolism or pneumonia) or
hip pain (e.g. arthritis).
Unilateral
Pain between the scapula\: spinal fracture, dissecting thoracic aortic aneurysm or myocardial infarction.
Onset
Clarify how and when the back pain developed\:
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e p a i n
" W h a t w e r e y o u d o i n g w h e n t h e p a i n
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e p a i n ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. dull ache, burning, tearing, sharp)
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
" I s t h e p a i n p r e s e n t a t r e s t ?"
" D o e s t h e p a i n w a k e y o u a t n i g h t ?"
Back pain that is present at rest and wakes the patient at night is typically associated with in
rheumatoid arthritis, ankylosing spondylitis) and malignancy (e.g. spinal metastases).
Pain that is described as burning in nature is typically neuropathic in origin (e.g. nerve root compression).
Tearing thoracic back pain is typically associated with aortic dissection.
Sharp back pain is less speci
Radiation
Ask if the back pain moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
Typical areas that back pain can radiate to include\:
Head (e.g. cervicogenic headache)
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 2/811/13/24, 8\:08 PM Guide | Back pain history
Buttocks or legs (e.g. sciatic nerve compression)
Upper/lower limbs (e.g. radiculopathy secondary to spinal nerve root compression)
Flank to the ipsilateral groin (e.g. renal colic)
Chest (e.g. myocardial infarction, dissecting aortic aneurysm)
Epigastrium (e.g. peptic ulcer disease)
Abdomen (e.g. constipation, abdominal aortic aneurysm dissection, ischaemic bowel)
Associated symptoms
Ask if there are other symptoms which are associated with the back pain\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?"
See the key symptoms section below for examples.
Time course
Clarify how the back pain has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
Exacerbating or relieving factors
Ask if anything makes the back pain worse or better\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?"
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?"
Triggers for back pain may include walking, coughing and lifting objects.
Relieving factors for back pain may include analgesia (e.g. paracetamol), muscle relaxants (e.g. diazepam) and lying down.
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"

Key symptoms to ask about

Key symptoms to ask about when taking a back pain history include\:
Motor or sensory disturbances\: suggestive of nerve root (i.e. radiculopathy) or spinal cord compression (e.g. cauda equina
syndrome). Ask speci
intervertebral disc, displaced vertebral fracture, haemorrhage and epidural abscess.
Urinary retention or incontinence\: typical features of cauda equina syndrome.
Haematuria\: may occur secondary to back trauma (due to renal injury), urinary tract infection and renal tract malignancy.
Fever\: typically associated with urinary tract infection, pneumonia and discitis.
Malaise\: associated with a wide range of pathology but in the context of back pain consider discitis or malignancy.
Weight loss\: associated with malignancy.
Early morning sti
Muscular spasms\: may be associated with spinal fracture or primary muscular injury.
Red
Red
Severe or progressive bilateral neurological de
ankle eversion, or foot dorsi
Recent-onset urinary retention and/or urinary incontinence
Recent-onset faecal incontinence
Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
Red
Sudden onset of severe central spinal pain which is relieved by lying down
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 3/811/13/24, 8\:08 PM Guide | Back pain history
There may be a history of major trauma (such as a road tra
strenuous lifting in people with osteoporosis or those who use corticosteroids
Red
Aged 50 or older
Gradual onset of symptoms
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain
aggravated by straining (e.g. opening bowels, coughing or sneezing), and thoracic pain
Localised spinal tenderness
No symptomatic improvement after four to six weeks of conservative lower back pain therapy
Unexplained weight loss
Past history of cancer\: breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasise
to the spine
Red
Fever
Tuberculosis, or recent urinary tract infection
Diabetes
History of intravenous drug use
HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised
Red
The red
Trauma
Unexplained weight loss
Neurological symptoms / signs
Age > 50
Fever
Intravenous drug use
Steroid use
History of cancer

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 4/811/13/24, 8\:08 PM Guide | Back pain history
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers (e.g. discitis), weight change (e.g. malignancy)
Cardiovascular\: chest pain (e.g. aortic dissection)
Respiratory\: dyspnoea, cough (e.g. pneumonia), pleuritic chest pain (e.g. pulmonary embolism)
Gastrointestinal\: abdominal pain (e.g. constipation)
Genitourinary\: loin pain, haematuria, dysuria (e.g. pyelonephritis)
Neurological\: headache (e.g. cervicogenic headache), motor or sensory disturbances (e.g. spinal cord compression)
Musculoskeletal\: trauma
Dermatological\: rashes (e.g. psoriasis)

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 5/811/13/24, 8\:08 PM Guide | Back pain history
Ask if the patient has previously had back problems and if so explore what treatments and investigations they received\:
" H a v e y o u h a d p r o b l e m s w i t h y o u r b a c k i n t h e p a s t ?"
" H a v e y o u e v e r b e e n g i v e n a d i a g n o s i s f o r y o u r b a c k p r o b l e m s ?"
" H a v e y o u p r e v i o u s l y h a d a n y s c a n s o r o t h e r i n v e s t i g a t i o n s f o r y o u r b a c k p r o b l e m ?"
Ask if the patient has previously undergone any surgery or procedures (e.g. spinal surgery)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical conditions
Medical history of particular relevance to back pain includes\:
Previous back problems including investigations and treatments
Osteoporosis (increased risk of spinal fracture)
Recent trauma
Scoliosis
Malignancy (risk of metastases)
Cardiovascular disease (e.g. myocardial infarction, aortic aneurysm)
Recent infections (e.g. UTIs - increased risk of discitis)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Medication examples
Medications commonly prescribed to patients with back pain\:
Paracetamol
NSAIDs (e.g. ibuprofen, diclofenac)
Opioids (e.g. codeine, tramadol, morphine)
Benzodiazepines (e.g. diazepam)
Pregabalin
Patients on corticosteroids are at an increased risk of developing fractures.

Family history

Ask the patient if there is any family history of back problems, in
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 6/811/13/24, 8\:08 PM Guide | Back pain history
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y b a c k p r o b l e m s o r a r t h r i t i s ?"
" I s t h e r e a n y f a m i l y h i s t o r y o f c a n c e r i n y o u r
" H a v e a n y o f y o u r

Social history

Explore the patient's social history to both understand their social context and identify potential risk factors for back pain.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for to determine their risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Smoking is an important risk factor for malignancy, osteoporosis, bone fractures and aortic aneurysms.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Chronic excessive alcohol use is a risk factor for osteoporosis and trauma.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is a risk factor for discitis.
Occupation
Ask about the patient's current occupation\:
Assess the impact of the back pain on their ability to work.
Clarify what their job role involves and identify tasks that increase the risk of back injury (e.g. heavy lifting).
Hobbies
Explore the patient's hobbies to identify potential risk factors for back injury (e.g. contact sports).

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. Sciatica (lumbar radiculopathy); NICE Clinical Knowledge Summary. Published\: April 2015. Available from\: [LINK].
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 7/811/13/24, 8\:08 PM Guide | Back pain history
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/history/back-pain-history/ 8/8